A Pictorial Guide to Complex Urinary Interventions

Learning Objectives: Demonstrate and review pathologies of the urinary collecting system requiring IR interventions

• Strictures, obstructions and leaks in setting of cancers, trauma and altered anatomy

Pictorially demonstrate standard and advanced techniques in IR

• Drainage/Diversion, recanalization (sharp and rendezvous), stenting (tandem/retrograde management) and ureteral occlusion

Background:

The urinary tract consists of long narrow conduits that can be compromised by various pathologies resulting in difficult-to-manage flow conditions from either narrowing, complete obstruction, leaks, or a combination of these issues. While surgical interventions are considered the gold standard, they are frequently limited by ongoing underlying pathology or high morbidity. Therefore, interventional radiologists are often employed to intervene with minimally invasive strategies. These treatments have various degrees of complexity, longer durations, and often require secondary interventions or long-term maintenance. The goal of this presentation is to provide a pictorial review of typical to complex pathologies, along with providing the learner with advanced techniques and strategies to maximize treatments and improve patient satisfaction.

Clinical Findings/Procedure Details:

1. Typical hydroureteronephrosis case in the setting of stricture-related pathology. Diversion via initial nephrostomy tube placement demonstrates ultrasound and fluoroscopic technique. Subsequent imaging showing stricture crossing and balloon treatment with subsequent case of single stent and tandem stent placements, providing details of antegrade crossing with stenting techniques, as well as tips for success.


2. Obstruction cases requiring sharp recanalization providing tips and pitfalls, as well as rendezvous techniques in the setting of ileal conduit and a urethral case using suprapubic access with retrograde urethral access.


3. Cases showing retrograde stent maintenance for ileal conduit, followed by examples of transurethral retrograde stent maintenance.


4. Urine leak cases with a case highlighting plug and glue ureteral occlusion as a definite treatment for vesicovaginal fistulae.

Conclusion and/or Teaching Points:

Urinary tract pathologies are often diverse and complex and require a good understanding of current treatment strategies. This tutorial should serve as a reference for both the upcoming and advancing interventionalist.